Public Health Units Report
Content
Report
A Survey for scaling of Public Health Units as Sub Centers, PHC and CHC of Uttar Pradesh State, India.
A Survey for Scaling heath units as Sub Centers, PHCs and CHCs in working area of CRY partners along with VOP District Advocacy coordinator working area in Uttar Pradesh State, India.
A Survey for scaling of Public Health Units of Uttar Pradesh
A Survey Report
A Survey for scaling of Public health units as Sub Centers, PHC and CHC in working area of CRY partners along with VOP District Advocacy coordinator working area in State of Uttar Pradesh, India.
By Voice of People 53, Maruti Puram, Indira Nagar, Lucknow-16 Phone: 0522 4042932 E-mail: [email protected] Blog: http://[email protected]
All rights reserved. No part of this survey may be reproduced in any form or by any means, or stored in a database or retrieval system, without prior permission of the publisher except in the case of brief quotations embodied in articles or reviews. Making copies of any part of this book for any purpose other than your own personal use is a violation of copyright laws. We have been careful to provide accurate information throughout this book, but it is possible that errors and omissions have been introduced. Please consider this in making any career plans or other important decisions.
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A Survey for scaling of Public Health Units of Uttar Pradesh
Executive Summery
Survey description and context
The Organization, Voice of People, undertook the study to evaluate the functioning of the public health facilities and their effectiveness in bringing health care services within the reach of people. On appropriate and feasible measures, the former is assessed on the static and dynamic condition of physical infrastructure; by the numbers of paramedical, technician and medical staff employed, as well as figures for attendance and gender breakdown; by the supply, quality and range of drugs; by availability and usage of decentralized untied and maintenance funding of centers; and by actual availability of laboratory, diagnostic and service facilities. Quality is defined in relation to the condition of the above tangibles, as also supplemented by subjective data on intangibles, such as patient satisfaction, gathered from the exit interviews.
Purpose of the Survey
The health system in Uttar Pradesh has witnessed major changes in public health in the recent decades. Post-independence, it has made significant strides on many health fronts and these must be rightfully acknowledged such as increased life expectancy, reduction in maternal and infant mortality and eradication of smallpox. However, the state is still far from achieving its population health goals.
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A Survey for scaling of Public Health Units of Uttar Pradesh
Now Uttar Pradesh existed among the states having worst health indicators in India. Even though some actions have been taken after the introduction of the National Rural Health Mission in late 2005, and some good outputs are emerging, a large number of very serious problems still remain. Without these problems being addressed, the targets regard to health and nutrition of India will not be met, since UP has such a large weight in the unmet needs of public health in India. High levels of maternal mortality, infant and child mortality and malnutrition continue to plague many parts of the Uttar Pradesh, coupled with significant variations across its districts. Together with maternal and newborn conditions, communicable diseases including HIV, TB, malaria, diarrhea and acute respiratory infections account for nearly half of Uttar Pradesh’s disease burden. Non-communicable conditions like cancers, cardiovascular disease, diabetes, COPD and mental health conditions account for the second largest share of the disease burden, now and in the future. Blindness and oral health conditions are also expected to increase sharply over the next decade (GOI, NCMH, 2005). The pressure of a burgeoning population, 72% of which is rural, with widespread illiteracy and social deprivation, pose a formidable challenge for the health sector’s functioning. Added to this is the response that is needed, in times of disaster and during sudden unexpected outbreaks of disease. Thus the single purpose of this survey is to understand the actual reasons behind the low levels of health indicators despite of a state wise multifunctioning public health facilities and human resource with a lot of funds from various governmental and nongovernmental agencies.
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A Survey for scaling of Public Health Units of Uttar Pradesh
Objectives of the survey
The very first and core objective of this survey is to use obtain data in future planning of various advocacy activities for all Uttar Pradesh in respect of health perspective. Identify and prioritize existing sources of available health services, particularly in rural areas. To provide data on the Primary services giving capacity on which they are meant to provide. To provide data on human resources, their presence and treatment towards community. To provide data on awareness of public towards various programs which government run for them. To provide data on Available infrastructure, equipment and their status on giving health care. medicines,
By this data we will lay the foundation for proper psychological, physical and social development of the child specially since they are future; To reduce the incidence of mortality, morbidity, malnutrition and school dropout; To achieve effective co-ordination of policy and implementation amongst the various governmental departments and non-profits organizations to promote child development; and
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A Survey for scaling of Public Health Units of Uttar Pradesh
To enhance the capability of the mother to look after the normal health and nutritional needs of the child through proper nutrition and health education.
Methodology
While the information available in published sources was obtained and used wherever necessary, the major part of the data required for the survey was generated through a sample survey. Thus, some district level statistics on health care infrastructure and health indicators were obtained from published documents, but the specific information on health care centers and knowledge and faith on those centers data had to be generated through collection of micro level information by the field units of VOP.
Features of a methodology
Information is gathered by asking questions to people.
Information is collected either by having interviewers ask questions and record answers or by having people read or hear questions and record their answers.
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A Survey for scaling of Public Health Units of Uttar Pradesh
Information is collected from only a subset of the population to be described (a sample) rather than from all members.
Process of Survey
Define research objectives
Choose mode of Collection
Choose sampling frame
Construct and pretest Questionnaire
Design and select sample
Recruit and measure sample
Code and edit data
Make post survey adjustments
Perform analysis
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A Survey for scaling of Public Health Units of Uttar Pradesh
Principle findings and conclusions
This paper seeks to evaluate quantity and quality of service delivery in public health facilities, looking to assess and measure the condition of physical infrastructure, both static and dynamic; the state of human resources, including numbers of paramedical, technician, medical and AYUSH staff employed, their contractual status, absenteeism and gender breakdown; the supply, quality and range of drugs; usage of decentralized untied and maintenance financial grants; and by actual availability of services in these centers. Quality is defined in relation to the condition of the above tangibles, as also supplemented by subjective data on intangibles, such as patient satisfaction, gathered from the exit interviews. The micro-findings, which have resulted in rankings in individual sections of the study, suggest disparate situations at various levels of centers and on different components, reflecting context-specific underlying driving factors, some complex by nature. Based on the findings and the arguments, I could easily rank the states on ‘overall performance of service delivery under’, and perhaps a reader already has a sense of this ranking. However, I feel that to do so would be irresponsible, meaningless and defeat the very purpose of this evaluation, which was to highlight the micro-components of features that are important to this Mission’s capacity to deliver services, how states are faring on implementing these various strands, and what factors might be causing problems where implementation is less than desirable.
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A Survey for scaling of Public Health Units of Uttar Pradesh
So to the question of whether the health care services has been delivered properly, the findings outlined here begin to give the nuanced answer that True, there are many problems in implementation, so that delivery is far from what is ought to be. On physical infrastructure, medicines and funding, problems might be more easily scaled with time (in some instances, they already appear to have been overcome), whereas on human resources, and to the extent these impact actual availability of services, structural issues of some complexity need careful resolving with a definite long term investment in the training and education of paramedical and medical staff, especially women staff, close monitoring of attendance. However, the parameters of the question this study seeks to answer are very much within the ambit of how to better performance, and not whether the Mission ought to have been undertaken in the first place, of which there can be no doubt. Especially relating to project objective / targets In terms of what the reader ought to take away from this study.
Key recommendations
Some PHCs and even CHCs have been running without any doctors. It’s not a carelessness of government but the government is mocking with people.
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A Survey for scaling of Public Health Units of Uttar Pradesh
Even 75 of health centers are running without proper equipment and medicines. Authorities have to deal it quickly. Geographical coverage is very large in case of PHCs and CHCs. They have inadequate medical staff, particularly the specialists. The mean distance of the PHCs from the CHC is longer. Some CHCs have been approved without sanctioning all the posts of specialists. Only 20 per cent of the required posts of the specialists were found to be in position. More than 80 per cent of the samples CHCs are running either with one specialist or without any specialist. There is a mis-match between medical specialists vis-a-vis equipment/facilities/ staff, leading to sub-optimal utilization of resources. The over-all productivity of the public health services can substantially be improved if this mis-match as well as thin spread of resources is avoided.
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A Survey for scaling of Public Health Units of Uttar Pradesh
Acknowledgements
The following people and organizations were instrumental in this Survey Project and deserve special recognition for their efforts:
Sponsors
Steering Committee
Survey Volunteers
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A Survey for scaling of Public Health Units of Uttar Pradesh
Table of Contents
List of Acronyms and Abbreviations
1. 2. 3. A. B. C. D. E. F. 4. 5. 6. 7.
Purpose of the survey Objectives of the survey Survey methodology Rationale for choice of methodology, data sources, methods for data collection and analysis, participatory techniques, ethical and equity considerations, major limitations of the methodology Survey findings Conclusions Recommendations Indexes
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A Survey for scaling of Public Health Units of Uttar Pradesh
List of Acronyms and Abbreviations ANM ARI ASHA AWW Auxiliary Nurse and Midwife Acute Respiratory Infection Accredited Social Health Activist Angadwadi Worker AYUSH Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy Community Health Centre Disposable Delivery Kit Direct Observes Treatment First Referral Unit Gross Domestic Product General Nurse and Midwife Government of India Iron Folic Acid Infant Mortality Rate Indian Public Health Standards Janani Suraksha Yojana Lady Health Visitor Maternal Mortality Rate Medical Officer Medical Officer In Charge National Rural Health Mission Out Patient Department Primary Health Centre Panchayati Raj Institution Reproductive and Child Health Rogi Kalyan Samiti Reproductive Tract Infection / Sexually Transmitted Infection Sub Centre Village Health and Sanitation Committee
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CHC DDK DOT FRU GDP GNM GOI IFA IMR IPHS JSY LHV MMR MO MOIC NRHM OPD PHC PRI RCH RKS RTI / STI SC VHSC
A Survey for scaling of Public Health Units of Uttar Pradesh
1. Purpose of the survey
Our health policy envisages a three tier structure comprising the primary, secondary and tertiary health care facilities to bring health care services within the reach of the people. The primary tier is designed to have three types of health care institutions, namely, a Sub-Centre (SC) for a population of 30005000, a Primary Health Centre (PHC) for 20000 to 30000 people and a Community Health Centre (CHC) as referral center for every four PHCs covering a population of 80,000 to 1.2 lakh. The district hospitals were to function as the secondary tier for the rural health care, and as the primary tier for the urban population. The tertiary health care was to be provided by health care institutions in urban areas which are well equipped with sophisticated diagnostic and investigative facilities. In pursuance of this policy, a vast network of health care institutions has been created, both in rural and urban areas, and substantial resources, though inadequate vis-a-vis requirement, have gone into planning and implementing the health and family welfare programs. This policy was applied to all states of India and increased availability and utilization of health care services have resulted in a general improvement of the health status of our population, as is reflected in the increased life expectancy and marked decline in birth and mortality rates over the last fifty years. However, these achievements are uneven, with marked disparities across states and districts, and between urban and rural people.
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A Survey for scaling of Public Health Units of Uttar Pradesh
The State of Uttar Pradesh has a vast infrastructure of medical installation throughout the state yet the status of the people of the Uttar Pradesh is not satisfactory as shown in the table below. Demographic, Socio-economic and Health profile of Uttar Pradesh State as compared to India figures
Item Total population (Census 2011) (in crore) Decadal Growth (Census 2011) (%) Crude Birth Rate (SRS 2010) Crude Death Rate (SRS 2010) Total Fertility Rate (SRS 2010) Infant Mortality Rate (SRS 2010) Maternal Mortality Ratio (SRS 2007 – 2009) Sex Ratio (Census 2011) Population below Poverty line (%) Schedule Caste population (in million) Schedule Tribe population (in million) Female Literacy Rate (Census 2011) (%)
Uttar Pradesh 19.96
20.09 28.3
India
121.01 17.64 22.1
8.1 3.5 61 359 908 31.15 35.15 0.11
59.26
7.2 2.5 47 212 940 26.10 166.64 84.33
65.46
Thus to find the real factors behind lacking of U.P. , this survey is required to evaluate the functioning of the Health Centre’s and their effectiveness in bringing basic and specialized health care within the reach of people.
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2. Objectives of the Survey
Identify and prioritize existing sources of available health services, particularly in rural areas. To provide data on the Primary services giving capacity on which they are meant to provide. To provide data on human resources, their presence and treatment towards community. To provide data on awareness of public towards various programs which government run for them. To provide data on Available infrastructure, equipment and their status on giving health care. medicines,
By this data we will lay the foundation for proper psychological, physical and social development of the child specially since they are future; To reduce the incidence of mortality, morbidity, malnutrition and school dropout; To achieve effective co-ordination of policy and implementation amongst the various governmental departments and non-profits organizations to promote child development; and To enhance the capability of the mother to look after the normal health and nutritional needs of the child through proper nutrition and health education.
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3.
Methodology
A. Rationale for choice of methodology A multi-stage sample design was adopted for the study. The sample units at different stages are: Sub Centre, CHCs and PHCs. Three separate formats were being made for these three type of medical installations. Following the above sample design, 224 patients, 155 non-patients households, 112 Sub Centers 40 PHCs and 26 CHCs spread over the 16 sample districts were selected for the study. In each selected village the views of knowledgeable persons were also taken for preparation of qualitative notes regarding the functioning of health care institutions. The separate rationales for all three stages are given below
I.
List of questions for Survey of Sub Centre Questions related to Sub Center had been divided in eight major sections and then sub sections of those main sections.
Section 1 - Services MCH Care including Family Planning; Availability of specific services Monitoring and Supervision activities
Section 2 - Manpower
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Section 3 - Physical Infrastructure (As per specifications) Location building, sanitation Electricity Water supply
Section 4 - Equipment (As per list)
Section 5 - Drugs (As per essential drug list)
Section 6 - Furniture (As per standards)
Section 7 - Quality Control
Section 8 - Views of Beneficiaries about Sub Centre Condition of their Health Certain knowledge of health programs and services which government running for them Availability of specific services
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II.
List of questions for Survey of Primary Health Centre Questions related to Primary Health Center had been divided in nine major sections and then sub section of those main sections.
Section 1- Services Assured Services available Treatment of specific cases MCH Care including Family Planning; Availability of specific services Monitoring and Supervision activities
Section 2- Manpower
Section 3- Training of personnel during previous (full) year
Section 4- Physical Infrastructure (As per specifications) Location Building, Sanitation Electricity Water supply
Section 5 - Equipment (As per list)
Section 6 - Drugs (As per essential drug list)
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Section 7- Furniture ( As per standards)
Section 8 - Quality Control
Section 9 - Views of Beneficiaries about PHC Condition of their Health Certain knowledge of health programs and services which government running for them Availability of specific services
III.
List of questions for Survey of Community Health Centre Questions related to Community Health Center had been divided in nine major sections and then sub sections of those main sections.
Section 1 - Services Specialist services available
Section 2- Manpower Clinical Manpower Support Manpower
Section 3 - Investigative Facilities
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Section 4 - Physical Infrastructure (As per specifications) Location Building, Sanitation Electricity Water supply Section 5 - Equipment (As per list)
Section 6 - Drugs (As per essential drug list)
Section 7- Furniture ( As per standards)
Section 8 - Quality Control
Section 9 - Views of Beneficiaries about CHC Condition of their Health Certain knowledge of health programs and services which government running for them Availability of specific services
B. Data sources While the information available in published sources was obtained and used wherever necessary, the major part of the data required for the study was generated through a sample survey.
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Thus, some district level statistics on health care infrastructure and health indicators were obtained from published documents, but the health care institution (SC/CHC/PHC) specific information and household level data had to be generated through collection of micro level information by the field units of VOP.
C. Methods for analysis Factor analysis technique was employed to examine the structure of the relationship among variables representing the perceived quality dimensions of healthcare services in Uttar Pradesh. The necessary data base was built through collection of both quantitative and qualitative data at various levels. To assess the location and coverage of health centers data pertaining to population coverage vis-a-vis norm prescribed, distance of sample and district Headquarters were collected. The information on availability and adequacy of health care service infrastructure, like, manpower, equipment, physical facilities was collected through health center level. To examine the utilization of referral services, the data on number of routine as well as referred cases attended at health centers per annum were collected. Besides, to assess the effectiveness of health centers, the primary information on accessibility and acceptability of health care services to the people was collected from beneficiaries. Thus, the requisite data base for the study was generated through the instruments of observation structured at different levels and also through discussions with Govt. Health functionaries. The
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instruments of observation were structured at six levels i.e. Sub Centre, CHC, PHC, knowledgeable person, patient and non-patient.
D. Participatory Techniques The study design was finalized in a meeting of the Heads of the Regional Offices of the VOP held on at the Regional Hq. The Head in turn held two Orientation Programs for field staff, one at Lucknow on 1th & 2th 2012 and on 17th & 18th September, 2012 . In these orientation programs, all the instruments prepared for the study were explained to the respective field teams of the selected districts.
E. Study Limitations The study has a number of limitations due to sampling and measurement methods. This study is not a pure experiment, because the intervention facilities were not randomly assigned, and the same patients were not interviewed at baseline and follow-up periods. A potential bias is that patients were interviewed for satisfaction at the facilities which may bias results upward. However, the effect should not be different between project and control sites at baseline and follow-up periods, so that the difference of difference measures should still be valid. The estimates of monthly averages for outpatient visits contained data that were incomplete, particularly at the PHCs. Although the project and control sites for outpatient visits were matched on district, this thin sample might not produce robust estimates.
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We could not find a systematic bias in the data, but we believe that the net effect of these changes is a random increase in the amount of error in our measurements. However, it does not change the main findings that utilization increased for all, especially the wealthier groups and that satisfaction with services increased at the CHCs and PHCs, and more consistently for the wealthier groups than the poor. Finally, caution must be used in interpreting the patient satisfaction ratings. Differences in perceptions may not be due to actual differences in quality. For example, it is not clear if CHC going groups express higher levels of satisfaction because the quality of services for them is better or because they have lower expectations.
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4. Survey findings
a) Findings from CHCs I.
Governmental norms for CHCs for reference CHCs are being established and maintained by the State Government under MNP/BMS program. As per minimum norms, a CHC is required to be manned by four medical specialists i.e. Surgeon, Physician, Gynecologist and Pediatrician supported by 21 paramedical and other staff. It has 30 in-door beds with one OT, X-ray, Labor Room and Laboratory facilities. It serves as a referral Centre for 4 PHCs and also provides facilities for obstetric care and specialist consultations.
II.
Section wise Survey Findings from CHCs Section 1 – Services
Services
Availability 72% NonAvailability 28%
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A Survey for scaling of Public Health Units of Uttar Pradesh
Section 2- Manpower
Manpower
Availability 57% NonAvailability 43%
Section 3 - Investigative Facilities
Investigative Facilities
NonAvailability 56% Availability 44%
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A Survey for scaling of Public Health Units of Uttar Pradesh
Section 4 - Physical Infrastructure (As per specifications)
Physical Infrastructure
Availability
84%
NonAvailability
16%
Section 5 - Equipment (As per list)
Equipment
Availability 95%
NonAvailability 5%
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A Survey for scaling of Public Health Units of Uttar Pradesh
Section 6 - Drugs (As per essential drug list)
Drugs
Availability 95%
NonAvailability 5%
Section 7- Furniture ( As per standards)
Furniture
Availability 68% NonAvailability 32%
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Section 8 - Quality Control
Quality Control
Availability 90%
NonAvailability 10%
Section 9 - Views of Beneficiaries about CHC
Views of Beneficiaries
NonAvailability 56%
Availability 44%
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III.
District
District Wise Findings
(Availability in percentage) S1 Services S2 Manpow er S3 Investigat ive Facilities Physic al Infrast ructur e S4 S5 Equip ment S6 Drugs S7 Furnitu re S8 Quality Control S9 Views of Beneficia ries
Allahabad Ambedkar Nagar Badaun Baharaich Chandauli Faizabad Kaushambi Lucknow Mahoba Mirjapur Sant Ravidas Nagar Sonebhadra Sultanpur Varanasi
66% 35% 54 49 39 40 61 80 46 36 47 52 48 47
45 40 51 66 43 48 43 35 56 55 46 37 46 44
32 34 23 45 25 45 34 45 56 36 46 56 23 34
67 76 65 76 65 67 76 65 76 65 56 67 76 43
84 55 65 23 57 84 55 65 23 57 64 84 55 64
54 56 67 47 26 54 56 67 47 26 48 54 56 63
67 76 65 76 65 44 35 54 87 56 67 44 35 43
84 55 65 23 57 46 66 46 87 54 67 46 66 55
54 56 67 47 26 37 64 53 61 53 54 37 64 56
IV. 1.
Findings In Detail
Average population covered
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Survey data suggest that a CHC covers an average of 175.2 l thousands people.
2. Health Infrastructure - Availability & Adequacy As the CHCs are required to deliver specialised health care services, it was decided to equip these institutions with suitable diagnostic and investigative facilities. As noted earlier, in addition to the usual staff and facilities, four medical specialists and other complementary Para medical staff and facilities, such as, operation theatre, labour room, pathology laboratory, X-ray machine, refrigerator, generator, etc., were prescribed by the Central Government to enable CHCs to deliver specialized health care services to rural people. A comparison of the availability of staff and facilities in the 26 sample CHCs with their prescribed norms shows wide gaps for the majority of the CHCs. In fact, most of them are not equipped to deliver the intended specialised health care services. In particular, the following inadequacies were observed some CHCs have been sanctioned without sanctioning all the posts of specialists;
Only 30 per cent of (the required posts) the specialists were found to be in position. More than 70 per cent of the samples CHCs are
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running either with one specialist (42%) or without any specialist (29%); The extent of shortfall in Para medical staff is found to be 12 per cent for NMWs, 16 per cent for Dressers and 39 per cent for Radiographers. At the aggregate level, pharmacists and laboratory technicians are found to be in excess of requirement; Out of 26 sample CHCs, operation theatres and labour rooms were not available in 5, pathology laboratories in 12, safe drinking water in 9, ECG machines in 23, X-ray machines in 12 and generators in 23 CHCs; What is more striking is the mis-match between the medical specialists and equipment/ facilities/ staff of CHCs. For example, only 6 sample CHCs had Surgeons with the essential complementary facilities comprising X-ray machines with Radiographers, pathology laboratories with lab-technicians and operation theatres, while 8 CHCs had Surgeons, 26 had operation theatres, etc. Similar mis-match is also noticed in the case of other specialists. All this tends to suggest that not only there is an acute shortage of medical specialists, but there is also a mis-match of facilities and specialists in a majority of CHCs, implying sub-optimal utilization and thin spread of available resources.
3. Utilization of Services Among the sample CHCs only two were found to have been used as referral centres to some extent.
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Eleven 11 CHCs have not attended to any referral cases, while the remaining have been used sub-optimally with an average of 206 cases per year. An attempt has been made in the study to identify the factors that explain the variation in the utilization of services across sample CHCs. Given the location and the coverage of area and population, the utilization rate depends on the ability of CHCs to deliver the complete package of services for specialised treatment. Variations in the availability of specialists, Para-medical staff, facilities for medical investigation, physical infrastructure and the complementarity among these Inputs are found to be responsible for differential utilization rates across CHCs. The above findings, however, should not lead one to conclude that the services of CHCs were not used at all. In fact, the entire sample CHCs were found functioning more like PHCs and attended to a large number of routine/direct cases.
4. Beneficiary’s Views An analysis of the views of the beneficiaries of the rural primary health care institutions revealed that about 57 per cent of them
were either dissatisfied or partially satisfied with the quality of services delivered through sample CHCs.
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The reasons for dissatisfaction stem from the inadequacies of the delivery system. Some of the major reasons for dissatisfaction are: non-availability of doctors, indifferent and non-sympathetic attitudes of doctors and Para medical staff and no availability of prescribed medicines. Of about 62 per cent of the total number of selected beneficiaries of sample CHCs, 76.8 per cent of the indoor patients and 54.8 per cent of the outdoor patients had spent money on getting treatment from CHCs. About 80 per cent of the expenditure of both indoor and outdoor patients was on medicines. Twenty eight (28) per cent of the indoor and 6 per cent of the outdoor patients had to spend more than Rs. 500 on each illness episode. It is interesting to note, however, that a large majority of the beneficiaries did not think that such expenses were a major constraint to the utilization of the services intended to be delivered through these CHCs. On the contrary, most of them expressed their preference for the public health institutions vis-àvis other alternatives.
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b) Findings From PHCs
I.
Governmental norms for PHCs for reference
PHC is the first contact point between village community and the Medical Officer. The PHCs were envisaged to provide an integrated curative and preventive health care to the rural population with emphasis on preventive and promote aspects of health care. The PHCs are established and maintained by the State Governments under the Minimum Needs Program (MNP)/ Basic Minimum Services (BMS) Program. As per minimum requirement, a PHC is to be manned by a two Medical Officer supported by 14 paramedical and other staff. Under NRHM, there is a provision for two additional Staff Nurses at PHCs on contract basis. It acts as a referral unit for 6 Sub Centre. It has 4 - 6 beds for patients. The activities of PHC involve curative, preventive, promote and Family Welfare Services.
II.
Section wise Survey Findings from PHCs
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A Survey for scaling of Public Health Units of Uttar Pradesh
Section 1 – Services
Services
Availability 72% NonAvailability 28%
Section 2- Manpower
Manpower
Availability 57%
NonAvailability 43%
Section 3 - Investigative Facilities
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Investigative Facilities
NonAvailability 56% Availability 44%
Section 4 - Physical Infrastructure (As per specifications)
Physical Infrastructure
Availability
84%
NonAvailability
16%
Section 5 - Equipment (As per list)
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A Survey for scaling of Public Health Units of Uttar Pradesh
Equipment
Availability 95%
NonAvailability 5%
Section 6 - Drugs (As per essential drug list)
Drugs
Availability 95%
NonAvailability 5%
Section 7- Furniture ( As per standards)
Furniture
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A Survey for scaling of Public Health Units of Uttar Pradesh
Section 8 - Quality Control
Quality Control
Availabilit y 90% NonAvailabilit y 10%
Section 9 - Views of Beneficiaries about PHC
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Views of Beneficiaries
NonAvailability 56%
Availability 44%
III.
District
District Wise Findings
S1 Services S2 Manpow er S3 Investigat ive Facilities Physic al Infrast ructur e S4 S5 Equip ment S6 Drugs (Availability in percentage) S7 S8 S9 Furnitu Quality Views of Beneficia re Control ries
Allahabad Aajamgarh Ambedkar Nagar Badaun Baharaich Chandauli Faizabad Lucknow
56 44 54 56 53 87 56 65
76 57 43 76 54 67 43 51
57 67 43 76 54 44 43 56
67 76 56 82 71 74 62 84
78 57 65 54 67 56 67 76
76 67 87 65 75 84 84 55
51 58 62 84 54 44 54 56
56 53 67 76 63 57 43 76
56 53 67 54 43 44 54 56
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Mahoba Muradabad Mirjapur Sant Ravidas Nagar Sonebhadra Sultanpur Varanasi
43 78 54 87 76 77 56
58 61 63 67 54 67 66
53 53 54 54 34 65 43
89 74 89 74 89 85 63
76 54 65 65 54 76 56
65 54 76 56 53 53 53
43 43 57 65 89 74 89
65 43 67 87 74 62 74
65 65 67 54 56 67 65
IV. I.
Findings In Detail
Average area covered
Survey data tells that a PHC covers an average of 74.7l thousand people.
II.
Manpower A drawback in the implementation of the family welfare program was the shortage of skilled and dedicated health
workers at the sub-center level followed by non-availability of a lady doctor at the PHC level. In most of the PHCs, male health workers were not available because of non-recruitment of vacancies during the last several years, as either they were retired or promoted. This has been
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happening at a crucial time when male involvement in family welfare is required. As a result, ANMs have taken on the responsibility of the disease control program. It has made them non- responsible and use this as an alibi for the ineffective implementation of the family welfare program. As the workload of ANMs increased, they were unable to give adequate time to the pregnant women and proper counseling, restricting their services only for providing TT injections and IFA tablets. Recently, a number of ANMs were appointed on contract but salaries were not given making them frustrated and disinterested in the work. The number of ANM supervisors was also found to be inadequate. Many of the health care providers suggested that encouragement to staff is important and regular training to upgrade skills are required. It was observed that ANMs were not well trained in IUD insertion and had no proper knowledge of the signs and symptoms of RTI/STIs.
Majority of the Medical Officer In-Charge (MOIC) opined that the Government should provide training to the workers. It was felt that the Chief Medical Officers (CMO) and Medical Officers (MOs) should give time for training the workers and build their capacity.
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A Survey for scaling of Public Health Units of Uttar Pradesh
III.
Physical Infrastructure (As per specifications) From the selected PHCs, all the 40 selected PHCs have their own building, but three of them needed major repairs, and most of them needed some repairs. Only three out of the PHC buildings were found to be in a good condition. It was also found that staff quarters were available in most of the PHCs, but doctors were not staying there. Water and sanitary facilities have great influence on health. It has been observed that in most of the PHCs the sources of water supply were either through hand pumps or tube wells. Water supply was reported to be adequate in most of the PHCs. Water supply to the existing toilets was not connected through a pipe. Because of this, although toilet facility was available in all the PHCs, several of them were not cleaned every day. It was found that all PHCs have electricity connection, but the supply of electricity was not regular. In most PHCs electricity supply was between seven to eight hours every day.
On the other hand, all PHCs have their own generator to restore power. Also, it was found that the majority of the PHCs have telephone facility.
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Although vehicles were available in majority of the PHCs, it was not in working condition. Similarly, it was also reported that drivers were not available in majority of the PHCs. In most of the PHCs, labour room and operation theatre was available, but exhaust fan was not fitted. All the PHCs had a separate dispensary room. The survey of infrastructure in the selected PHCs showed that barring the regular supply of electricity, all other facilities were more or less available, but the proper use and maintenance of the existing facilities was not ensured. It was also observed that a large number of posts were lying vacant both among the medical and para medical categories, including that of Medical Officer and male MPHWs (Multi Purpose Health Worker), which are key positions.
Recently, temporary ANMs were appointed known as RCH-ANMs, but their numbers were few in each district. There were also a large number of posts found vacant belonging to other employee category, such as drivers, peons, chaukidars, dais and sweepers. This has an impact on cleanliness and maintenance infrastructure at the PHC level.
IV.
Availability of Equipment and Drugs It was reported that the supply of drugs, vaccines, and contraceptives were regular from district to the PHCs, but the
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supply of vaccines was not adequate and regular, particularly BCG and measles. It is also noted that the records on the distribution of drugs, vaccines and contraceptives were not properly maintained. Usually, contraceptives, vaccines and drugs are equally distributed among all the PHCs. There is a need to rationalize the distribution of contraceptive vaccines and drugs to each PHC. However, ANMs did not have delivery kits, stethoscope and BP instruments.
V.
Knowledge and views of beneficiaries Knowing the availability of facilities at the Primary Health Centres is not adequate unless we also take into account the opinion of the clients. Considering this, it was decided to conduct exit interviews of the clients at the PHCs. There were 265 clients interviewed from 40 PHCs of Uttar Pradesh. The most frequently stated health problem for which the clients sought treatment was for fever, cough and cold, diarrhea, etc.
The purpose of visiting the PHC for family planning, ANC and reproductive health was comparatively less. However, more women came for family planning and child care than men, but there was little difference in treatment seeking for reproductive morbidities.
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Treatment seeking behavior and utilization of services at PHCs shows that family planning was not an important concern for clients who visited the PHC for availing services. Also, reproductive health care seeking is almost negligible at the PHC level. This shows that demand for family planning and reproductive health services from the government sources is not high.
c) Findings from Sub Centers I.
Governmental norms for Sub Centers for reference
The Sub-Centre is the most peripheral and first contact point between the primary health care system and the community. Each Sub-Centre is required to be manned by at least one Auxiliary Nurse Midwife (ANM) / Female Health Worker and one Male Health Worker. Under NRHM, there is a provision for one additional second ANM on contract basis. One Lady Health Visitor (LHV) is entrusted with the task of supervision of six Sub-centres. Sub-Centre are assigned tasks relating to interpersonal communication in order to bring about behavioral change and provide services in relation to maternal and child health, family
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welfare, nutrition, immunization, diarrhea control and control of communicable diseases programs. The Sub-centers are provided with basic drugs for minor ailments needed for taking care of essential health needs of men, women and children. The Ministry of Health & Family Welfare is providing 100% Central assistance to all the Sub-centers in the country since April 2002 in the form of salary of ANMs and LHVs, rent at the rate of Rs. 3000/- per annum and contingency at the rate of Rs. 3200/- per annum, in addition to drugs and equipment kits. The salary of the Male Worker is borne by the State Governments. Each sub-Centre will have an Untied Fund for local action @ Rs. 10,000 per annum (as per NRHM 05-12). This Fund will be deposited in a joint Bank Account of the ANM & Sarpanch and operated by the ANM, in consultation with the Village Health Committee.
II.
Section wise Survey Findings from Sub Centers Section 1 – Services
Services
Availability 72%
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NonAvailability 28%
A Survey for scaling of Public Health Units of Uttar Pradesh
Section 2- Manpower
Manpower
Availability 57% NonAvailability 43%
Section 3 - Physical Infrastructure (As per specifications)
Physical Infrastructure
Availability
84%
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Non-
A Survey for scaling of Public Health Units of Uttar Pradesh
Availability
A Survey for scaling of Public Health Units of Uttar Pradesh
Section 4 - Equipment (As per list)
Equipment
Availability 95%
NonAvailability 5%
Section 5 - Drugs (As per essential drug list)
Drugs
Availability 95%
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NonAvailability 5%
A Survey for scaling of Public Health Units of Uttar Pradesh
Section6- Furniture (As per standards)
Services
Availability 68% NonAvailability 32%
Section 7 - Quality Control
Quality Control
Availability 90%
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NonAvailability 10%
A Survey for scaling of Public Health Units of Uttar Pradesh
Section 8 - Views of Beneficiaries about Sub Centers
Views of Beneficiaries
NonAvailability 56%
Availability 44%
III.
District
District Wise Findings
S1 Service s S2 Manpower S3 Physical Infrastruc ture S4 Equip ment S5 Drugs (Availability in percentage) S6 S7 S8 Furnitu Quality Views of re Control Beneficia ries
Allahabad Aajamgarh Ambedkar Nagar Badaun
45 56 65 63
34 62 84 89
65 67 76 76
43 84 55 65
43 54 56 43
33 43 76 65
45 56 73 45
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47 76 56 45
A Survey for scaling of Public Health Units of Uttar Pradesh
Baharaich Chandauli Faizabad Kaushambi Mahoba Mirjapur Sant Ravidas Nagar Sonebhadra Sultanpur Varanasi
36 64 56 45 58 54 87 44 76 67
74 89 74 65 67 76 65 76 65 56
54 65 65 43 84 55 65 23 57 64
54 76 56 43 54 56 67 47 26 48
43 57 65 74 44 35 54 87 56 67
43 67 87 56 46 66 46 87 54 67
45 34 75 56 37 64 53 61 53 54
34 54 46 65 43 78 43 36 74 74
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IV.
Findings In Detail
I.
Average area covered Survey data tells that a Sub-Centre covers an average of 5.8 thousand people. II. General Findings When it comes to basic infrastructure facilities in the sub-centers, it is encouraging that most of the sub-centers seem to have some sort of basic physical structure present with 40 out of 112 subcenters having more than one room. However it is a matter of concern that nearly half the sub-centers did not have electricity or sanitation, and 15 out of 112 sub centers had buildings in poor dilapidated conditions. Water was available in 48 out of 112 of the sub centers but toilets were not available in 33 out of 71 of the sub centers.
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Sub Center should provide contraceptives like pills, condoms as well as generic medicines for common ailments like fever. 46 out of 112 sub-centers reported having contraceptive pills while 41 out of 112 sub-centers had condoms available. Medicine for fever was available in 37 out of 112 sub-centers. Ante-natal services for pregnant women are one of most important service that village level sub centers should provide. It is encouraging that iron-tablets that are meant to be regularly provided to pregnant women were available in around 2/3 of the sub centers. However only 27 out of 112 again sub-centers were reported providing ante-natal check-ups. Basic instruments like weighing machine and blood pressure measuring instruments are needed for pre-natal check-ups: more than half sub-centers did not have weighing machines and 49 out of 112 sub centers did not have instrument for measuring blood pressure. Sub-centers should be able to handle normal deliveries at the local level. However some of the basic requirements to handle a delivery were missing. Nearly half the sub centers did not have a bed and 72 out of 112 did not have curtains near the bed for privacy. Other basic things like gloves were absent in half the sub-centers as well as stove required for sterilizing was missing in 57 out of 112 villages.
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5. CONCLUSIONS
Mostly clean, green and well maintained CHCs and committed team; Very spacious CHC buildings; Lack electricity supply in most CHCs; PHCs and SCs need more maintenance; Power supply is erratic; Generators and inverters not available in most places; Bio Medical Waste management needs attention;
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Mobile medical Units not operationalized; Transport constraints for field workers and patients; Shortage of Human resources at all levels; Those in position work hard to deliver health care; Acute shortage of MPW (M); Training process need fast tracking, multi skill training for doctors, IMNCI, IDSP, SBA training, ASHA training; Limited promotional avenues for doctors and para medicals ; Post-delivery stay in the facilities is very short- need monitoring system; Shortage of space leads to compromise with quality; Delivery load is more on few facilities; New Born care services need strengthening; Passive screening for communicable diseases needs to be strengthened; Active screening for communicable diseases ( Malaria) needs more attention;
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Basic non communicable disease screening fixed day services needed; Hospital level Diabetes , Hypertension clinic, cancer cervix screening, RTI/STI clinics, Integrated counseling and Testing Centres needed in all 24 x 7 facilities; Poor voluntary blood donation – insisting on relative donor; Institutional deliveries improved; Awareness on MCH services very high in the community; Adequate drug supply; Poor availability of MTP/ MVA services; centres needed for provision of tubectomy services; Convergence needs more attention; Lab services at peripheral centers poorly equipped – Lack of reagents and Consumables; ANMs and ASHAs are well accepted and respected in the community; PRIs not uniformly involved for VHSC; VHSC recently instituted but not yet active;
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Clear Guidelines for the use of funds needed; Timely payment to JSY beneficiaries needed; It is commonly known that women are often the last to access health care in a poor family. Distance of the health-center and cost of treatment may act as important factors that determine women’s access to primary healthcare; Given the easy location of the sub centers, it has the potential to increase access to primary healthcare for women; However as the data suggests, many sub-centers lack basic facilities like water, electricity or toilets, which raise serious questions about quality of care provided; UP being one of the worst states when it comes to maternal health indicators, the importance of ante natal care is immense. Much of the problems associated with maternal death can be averted if there is early detection of anemia, low weight, blood pressure etc; However, as the data suggests, more than half the sub centers are not providing antenatal check-ups, thereby increasing the load on higher level of facilities. Sub- centers were found to be ill equipped to handle normal deliveries, with nearly half the subcenters not even having beds. Easy availability of quality contraceptives is integral for women to have control over reproductive decision making and avoid unwanted pregnancies;
Yet, not all sub-centres had even contraceptive facilities;
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6. Recommendations
1. General Recommendations
1. Manpower deficit should be addressed urgently. Mapping of human resource and redistribution is required. More doctors, staff nurse, Public Health Nurse, Pharmacists need to be recruited. General duty medical officers with public health expertise and management skills are to be posted at primary care facilities. For this creation of a public health cadre is very justified. As the clinicians and specialists currently posted at various facilities are neither able to provide specialist services due to lack of facilities not able to implement national health programs and provide leadership to public health team due to lack of managerial skills. 2. The doctors posted at most of the facilities are either specialists or MBBS with clinical orientation. They lack understanding of public health perspectives and integrated approach to health care.
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ANMs recruited in 1980s are old now and not able to deliver with efficiency of young women. A large number of them are going to retire in next couple of years. It is the right time to tackle this issue before a new human resource crisis emerges in this segment. ANMs having become an experienced work force, require to be promoted to supervisory levels and new young ANMs need to be recruited in order to improve field work. 3. It is recommended that public health specialists and specialists in community medicine/family medicine should be posted at the primary health care facilities. They will be able to take care of primary health care needs of the community, implement national health programs and provide managerial/administrative leadership to his team of primary health care. Creation of a separate public health cadre will be able to fulfill this need of public health managers at various levels of health care facility. 4. Training program for MPW(M) and diploma courses for nurses in Maternal and New born care as well as career progression scheme for them may improve their functioning. 5. The working conditions and incentives for working in rural area should be so rewarding that it does not make the incumbent feel disadvantaged compared to his/her counterpart working in urban areas and private sector. 6. Provision of interest free loans for buying moped/two wheelers or providing mopeds may improve out reach service delivery component of primary health care. 7. Community participation and community ownership is grossly lacking. People are not aware of their rights and responsibilities. Sensitization and awareness generation among the people need to
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be improved, particularly in rural areas. The signage showing citizens charters and informing people about salient features of programs like Janani Suraksha Yojana should not be restricted to health facilities. These need to be displayed in villages and prominent market places as well. 8. Monitoring and supervision is another area that needs to be improved. With aging and retirement of LHVs, supervision process is diluted. Through promotion of ANMs and recruitment of new LHVs, this can be taken care of. 9. Shortage of Male Multi Purpose Worker also need to be addressed. 10. Political interference in manpower recruitment as well as in day to governance is a great hindrance in smooth functioning of health care system. Even the involvement of Panchayati Raj Institutions has proved counterproductive in some areas, particularly when it becomes a key determinant in recruitment and transfer of workers, protection of erring workers. Mass media campaigns should also be used to inform the community about the facilities created under these new programs and their benefits. 11. Safety and security of ANMs and other female workers is a matter of concern in some areas. There are plenty of instances of manhandling and molestation of single female workers in the field area and the culprits getting away with. 12. Rationalization of services at different levels following IPH standards is recommended.
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13. Neonatal referral units to be provided in all district hospitals and basic new born care units in all CHCs and 24x7 facilities should be made available. 16. Establish modern blood bank with blood component separation units. 17. Rapid implementation of IDSP should be ensured. 18. Some of the facility buildings are located far from the villages, in a remote isolated corner, thus making it less accessible and a deterrent for ANM to stay there. 19. With the financial incentives being paid to the beneficiaries for services availed, an opportunity presents itself: availability of validated output indicators. A major deficiency of public sector programming, namely availability of only process indicators, can now be overcome. The ability to determine performance of individual providers and centres can become a very useful management tool for strengthening the programs in the time ahead. 20. With JSY gaining rapid acceptance, the number of obstetric emergencies being brought to the institutions will also go up. The system needs to get itself ready for these cases at CHC and PHC levels. 21. Non communicable diseases control program and vector borne diseases control programs are not yet being implemented at the peripheral level. This needs to be strengthened. 22. Nutrition supplementation, nutrition rehabilitation and provision of food for mothers after delivery and after tubectomy
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operations should be made at all facilities where these services are being provided. 24. Better monitoring and supportive supervision of all programs should be ensured by monthly review by district magistrates, use of structured inspection forms and follow up schedules. 25. Rapid grievance redress for staff and beneficiaries should be ensured. 26. Community participation and social audit should be encouraged.
Appendix -I
List of Surveyed Centers
CHCs:
Sl. No. District CHC Saray Lili Jasra Shankergarh Kaundhiara Akbarpur Tanda Ujhani
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1
Allahabad
2 3
Ambedkar Nagar Badaun
A Survey for scaling of Public Health Units of Uttar Pradesh
4 5 6 7 8 9 10 11 12
Baharaich Chandauli Faizabad Kaushambi Lucknow Mahoba Mirjapur Sant Ravidas Nagar Sonebhadra Sultanpur Varanasi
Kakrala Dataganj Motipur Naugarh Chakia Sohawal Bara Chinhat Bakshi Ka Talab Charkhari Rajgarh Suriyawn Chopan Myopur Ghorawal Akhand Nagar Puarikala Cholapur Gangapur
13 14
PHCs:
Sl. No. 1 District Allahabad PHC Kotwa Bara Jaari Badagaon Jamnipur Bewana Tarakhurd
2
Ambedkar Nagar
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3
Azamgarh
Badhalganj Jagat Kadarchowk Myoun Usaihat Uswan Sujauli Amba Shikarganj
4
Badaun
5
Baharaich
6
Chandauli
7 8 9
Faizabad Kaushambi Lucknow
Chakia Amdaha Milkipur Sohawal Karari Baishkhari Kathwara Rustampur Varni Allipur Narauli Akrauli Patehra Kala Padri Kasya Mahjuda Myopur Salkhan Parsona Mudila Rupaipur
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10
Muradabad
11 12
Mirjapur Sant Ravidas Nagar
13
Sonebhadra
14
Sultanpur
A Survey for scaling of Public Health Units of Uttar Pradesh
Harhua 15 Varanasi Badagaon Chiraigaon Pindara
Sub Centers:
Sl. No.
District
Sub Center Gara Katra Biharia Jorhat Baghla Biharia Kalyanpur Gulalpur Bara Khanti Jaari Janwa GaraaaKatra Bansgaon Airakala
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1
Allahabad
2
Aajamgarh
A Survey for scaling of Public Health Units of Uttar Pradesh
3
Ambedkar Nagar
Tisaura Ilfatganj Banwa Tajpur Naipura Naugawan Asharfa Bad Kataria Silwan Makdumpur Kathauna Sanjarpur Abdullaganj Viola Naushera Sisora Sathara Bhundi Gathauna Kurau Sarali Bahu Nagla Bhagautipur Hazaratpur Uharpur Kishni Gidhaul Ikari Jagat Chilor Monipatti Gautra
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4
Badaun
A Survey for scaling of Public Health Units of Uttar Pradesh
Koda Jaikaran Nagariya Chikan Bilhari Myaun Dehat Harendi Labhari Gurgaon JamalPur Ranviganj Varsua 5 Baharaich Gathuna Girijapuri Amdaha 6 Chandauli Nevadganj Shikarganj Baliakala Shahganj Raunai Para Hasanpur Baiskati Karari Pawara Mangura Pindara Gubara Sirchanpur Danpur Saibasa Chak Sayyadpur Mawana Alam Aadilpur
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7
Faizabad
8
Kaushambi
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9
Mahoba
Ranipur Gaurahi Kharela Kanhaipur Sarson Golhanpur Bachaura Aitraila Raikara Dashrath Nevada Kusuda Chattar Shahpur Persona Bhawana Kadia Shivdwar Salkhan Pehadwa Markundi Kirbil Nipraj Aarang Pani Lilasi Loknathpur Unurukha Bahauddin Mailkpur Unrukha Rupaipur Shivrampur Velvariya
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10
Mirjapur
11
Sant Ravidas Nagar
12
Sonebhadra
13
Sultanpur
14
Varanasi
A Survey for scaling of Public Health Units of Uttar Pradesh
Aanei Aapar Mangari Machli gaon Parmandapur Belva Saray Mohan Nathaipur
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A Survey for scaling of Public Health Units as Sub Centers, PHC and CHC of Uttar Pradesh State, India.
A Survey for Scaling heath units as Sub Centers, PHCs and CHCs in working area of CRY partners along with VOP District Advocacy coordinator working area in Uttar Pradesh State, India.
A Survey for scaling of Public Health Units of Uttar Pradesh
A Survey Report
A Survey for scaling of Public health units as Sub Centers, PHC and CHC in working area of CRY partners along with VOP District Advocacy coordinator working area in State of Uttar Pradesh, India.
By Voice of People 53, Maruti Puram, Indira Nagar, Lucknow-16 Phone: 0522 4042932 E-mail: [email protected] Blog: http://[email protected]
All rights reserved. No part of this survey may be reproduced in any form or by any means, or stored in a database or retrieval system, without prior permission of the publisher except in the case of brief quotations embodied in articles or reviews. Making copies of any part of this book for any purpose other than your own personal use is a violation of copyright laws. We have been careful to provide accurate information throughout this book, but it is possible that errors and omissions have been introduced. Please consider this in making any career plans or other important decisions.
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A Survey for scaling of Public Health Units of Uttar Pradesh
Executive Summery
Survey description and context
The Organization, Voice of People, undertook the study to evaluate the functioning of the public health facilities and their effectiveness in bringing health care services within the reach of people. On appropriate and feasible measures, the former is assessed on the static and dynamic condition of physical infrastructure; by the numbers of paramedical, technician and medical staff employed, as well as figures for attendance and gender breakdown; by the supply, quality and range of drugs; by availability and usage of decentralized untied and maintenance funding of centers; and by actual availability of laboratory, diagnostic and service facilities. Quality is defined in relation to the condition of the above tangibles, as also supplemented by subjective data on intangibles, such as patient satisfaction, gathered from the exit interviews.
Purpose of the Survey
The health system in Uttar Pradesh has witnessed major changes in public health in the recent decades. Post-independence, it has made significant strides on many health fronts and these must be rightfully acknowledged such as increased life expectancy, reduction in maternal and infant mortality and eradication of smallpox. However, the state is still far from achieving its population health goals.
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Now Uttar Pradesh existed among the states having worst health indicators in India. Even though some actions have been taken after the introduction of the National Rural Health Mission in late 2005, and some good outputs are emerging, a large number of very serious problems still remain. Without these problems being addressed, the targets regard to health and nutrition of India will not be met, since UP has such a large weight in the unmet needs of public health in India. High levels of maternal mortality, infant and child mortality and malnutrition continue to plague many parts of the Uttar Pradesh, coupled with significant variations across its districts. Together with maternal and newborn conditions, communicable diseases including HIV, TB, malaria, diarrhea and acute respiratory infections account for nearly half of Uttar Pradesh’s disease burden. Non-communicable conditions like cancers, cardiovascular disease, diabetes, COPD and mental health conditions account for the second largest share of the disease burden, now and in the future. Blindness and oral health conditions are also expected to increase sharply over the next decade (GOI, NCMH, 2005). The pressure of a burgeoning population, 72% of which is rural, with widespread illiteracy and social deprivation, pose a formidable challenge for the health sector’s functioning. Added to this is the response that is needed, in times of disaster and during sudden unexpected outbreaks of disease. Thus the single purpose of this survey is to understand the actual reasons behind the low levels of health indicators despite of a state wise multifunctioning public health facilities and human resource with a lot of funds from various governmental and nongovernmental agencies.
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Objectives of the survey
The very first and core objective of this survey is to use obtain data in future planning of various advocacy activities for all Uttar Pradesh in respect of health perspective. Identify and prioritize existing sources of available health services, particularly in rural areas. To provide data on the Primary services giving capacity on which they are meant to provide. To provide data on human resources, their presence and treatment towards community. To provide data on awareness of public towards various programs which government run for them. To provide data on Available infrastructure, equipment and their status on giving health care. medicines,
By this data we will lay the foundation for proper psychological, physical and social development of the child specially since they are future; To reduce the incidence of mortality, morbidity, malnutrition and school dropout; To achieve effective co-ordination of policy and implementation amongst the various governmental departments and non-profits organizations to promote child development; and
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A Survey for scaling of Public Health Units of Uttar Pradesh
To enhance the capability of the mother to look after the normal health and nutritional needs of the child through proper nutrition and health education.
Methodology
While the information available in published sources was obtained and used wherever necessary, the major part of the data required for the survey was generated through a sample survey. Thus, some district level statistics on health care infrastructure and health indicators were obtained from published documents, but the specific information on health care centers and knowledge and faith on those centers data had to be generated through collection of micro level information by the field units of VOP.
Features of a methodology
Information is gathered by asking questions to people.
Information is collected either by having interviewers ask questions and record answers or by having people read or hear questions and record their answers.
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A Survey for scaling of Public Health Units of Uttar Pradesh
Information is collected from only a subset of the population to be described (a sample) rather than from all members.
Process of Survey
Define research objectives
Choose mode of Collection
Choose sampling frame
Construct and pretest Questionnaire
Design and select sample
Recruit and measure sample
Code and edit data
Make post survey adjustments
Perform analysis
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A Survey for scaling of Public Health Units of Uttar Pradesh
Principle findings and conclusions
This paper seeks to evaluate quantity and quality of service delivery in public health facilities, looking to assess and measure the condition of physical infrastructure, both static and dynamic; the state of human resources, including numbers of paramedical, technician, medical and AYUSH staff employed, their contractual status, absenteeism and gender breakdown; the supply, quality and range of drugs; usage of decentralized untied and maintenance financial grants; and by actual availability of services in these centers. Quality is defined in relation to the condition of the above tangibles, as also supplemented by subjective data on intangibles, such as patient satisfaction, gathered from the exit interviews. The micro-findings, which have resulted in rankings in individual sections of the study, suggest disparate situations at various levels of centers and on different components, reflecting context-specific underlying driving factors, some complex by nature. Based on the findings and the arguments, I could easily rank the states on ‘overall performance of service delivery under’, and perhaps a reader already has a sense of this ranking. However, I feel that to do so would be irresponsible, meaningless and defeat the very purpose of this evaluation, which was to highlight the micro-components of features that are important to this Mission’s capacity to deliver services, how states are faring on implementing these various strands, and what factors might be causing problems where implementation is less than desirable.
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So to the question of whether the health care services has been delivered properly, the findings outlined here begin to give the nuanced answer that True, there are many problems in implementation, so that delivery is far from what is ought to be. On physical infrastructure, medicines and funding, problems might be more easily scaled with time (in some instances, they already appear to have been overcome), whereas on human resources, and to the extent these impact actual availability of services, structural issues of some complexity need careful resolving with a definite long term investment in the training and education of paramedical and medical staff, especially women staff, close monitoring of attendance. However, the parameters of the question this study seeks to answer are very much within the ambit of how to better performance, and not whether the Mission ought to have been undertaken in the first place, of which there can be no doubt. Especially relating to project objective / targets In terms of what the reader ought to take away from this study.
Key recommendations
Some PHCs and even CHCs have been running without any doctors. It’s not a carelessness of government but the government is mocking with people.
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Even 75 of health centers are running without proper equipment and medicines. Authorities have to deal it quickly. Geographical coverage is very large in case of PHCs and CHCs. They have inadequate medical staff, particularly the specialists. The mean distance of the PHCs from the CHC is longer. Some CHCs have been approved without sanctioning all the posts of specialists. Only 20 per cent of the required posts of the specialists were found to be in position. More than 80 per cent of the samples CHCs are running either with one specialist or without any specialist. There is a mis-match between medical specialists vis-a-vis equipment/facilities/ staff, leading to sub-optimal utilization of resources. The over-all productivity of the public health services can substantially be improved if this mis-match as well as thin spread of resources is avoided.
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Acknowledgements
The following people and organizations were instrumental in this Survey Project and deserve special recognition for their efforts:
Sponsors
Steering Committee
Survey Volunteers
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Table of Contents
List of Acronyms and Abbreviations
1. 2. 3. A. B. C. D. E. F. 4. 5. 6. 7.
Purpose of the survey Objectives of the survey Survey methodology Rationale for choice of methodology, data sources, methods for data collection and analysis, participatory techniques, ethical and equity considerations, major limitations of the methodology Survey findings Conclusions Recommendations Indexes
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List of Acronyms and Abbreviations ANM ARI ASHA AWW Auxiliary Nurse and Midwife Acute Respiratory Infection Accredited Social Health Activist Angadwadi Worker AYUSH Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy Community Health Centre Disposable Delivery Kit Direct Observes Treatment First Referral Unit Gross Domestic Product General Nurse and Midwife Government of India Iron Folic Acid Infant Mortality Rate Indian Public Health Standards Janani Suraksha Yojana Lady Health Visitor Maternal Mortality Rate Medical Officer Medical Officer In Charge National Rural Health Mission Out Patient Department Primary Health Centre Panchayati Raj Institution Reproductive and Child Health Rogi Kalyan Samiti Reproductive Tract Infection / Sexually Transmitted Infection Sub Centre Village Health and Sanitation Committee
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CHC DDK DOT FRU GDP GNM GOI IFA IMR IPHS JSY LHV MMR MO MOIC NRHM OPD PHC PRI RCH RKS RTI / STI SC VHSC
A Survey for scaling of Public Health Units of Uttar Pradesh
1. Purpose of the survey
Our health policy envisages a three tier structure comprising the primary, secondary and tertiary health care facilities to bring health care services within the reach of the people. The primary tier is designed to have three types of health care institutions, namely, a Sub-Centre (SC) for a population of 30005000, a Primary Health Centre (PHC) for 20000 to 30000 people and a Community Health Centre (CHC) as referral center for every four PHCs covering a population of 80,000 to 1.2 lakh. The district hospitals were to function as the secondary tier for the rural health care, and as the primary tier for the urban population. The tertiary health care was to be provided by health care institutions in urban areas which are well equipped with sophisticated diagnostic and investigative facilities. In pursuance of this policy, a vast network of health care institutions has been created, both in rural and urban areas, and substantial resources, though inadequate vis-a-vis requirement, have gone into planning and implementing the health and family welfare programs. This policy was applied to all states of India and increased availability and utilization of health care services have resulted in a general improvement of the health status of our population, as is reflected in the increased life expectancy and marked decline in birth and mortality rates over the last fifty years. However, these achievements are uneven, with marked disparities across states and districts, and between urban and rural people.
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The State of Uttar Pradesh has a vast infrastructure of medical installation throughout the state yet the status of the people of the Uttar Pradesh is not satisfactory as shown in the table below. Demographic, Socio-economic and Health profile of Uttar Pradesh State as compared to India figures
Item Total population (Census 2011) (in crore) Decadal Growth (Census 2011) (%) Crude Birth Rate (SRS 2010) Crude Death Rate (SRS 2010) Total Fertility Rate (SRS 2010) Infant Mortality Rate (SRS 2010) Maternal Mortality Ratio (SRS 2007 – 2009) Sex Ratio (Census 2011) Population below Poverty line (%) Schedule Caste population (in million) Schedule Tribe population (in million) Female Literacy Rate (Census 2011) (%)
Uttar Pradesh 19.96
20.09 28.3
India
121.01 17.64 22.1
8.1 3.5 61 359 908 31.15 35.15 0.11
59.26
7.2 2.5 47 212 940 26.10 166.64 84.33
65.46
Thus to find the real factors behind lacking of U.P. , this survey is required to evaluate the functioning of the Health Centre’s and their effectiveness in bringing basic and specialized health care within the reach of people.
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2. Objectives of the Survey
Identify and prioritize existing sources of available health services, particularly in rural areas. To provide data on the Primary services giving capacity on which they are meant to provide. To provide data on human resources, their presence and treatment towards community. To provide data on awareness of public towards various programs which government run for them. To provide data on Available infrastructure, equipment and their status on giving health care. medicines,
By this data we will lay the foundation for proper psychological, physical and social development of the child specially since they are future; To reduce the incidence of mortality, morbidity, malnutrition and school dropout; To achieve effective co-ordination of policy and implementation amongst the various governmental departments and non-profits organizations to promote child development; and To enhance the capability of the mother to look after the normal health and nutritional needs of the child through proper nutrition and health education.
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3.
Methodology
A. Rationale for choice of methodology A multi-stage sample design was adopted for the study. The sample units at different stages are: Sub Centre, CHCs and PHCs. Three separate formats were being made for these three type of medical installations. Following the above sample design, 224 patients, 155 non-patients households, 112 Sub Centers 40 PHCs and 26 CHCs spread over the 16 sample districts were selected for the study. In each selected village the views of knowledgeable persons were also taken for preparation of qualitative notes regarding the functioning of health care institutions. The separate rationales for all three stages are given below
I.
List of questions for Survey of Sub Centre Questions related to Sub Center had been divided in eight major sections and then sub sections of those main sections.
Section 1 - Services MCH Care including Family Planning; Availability of specific services Monitoring and Supervision activities
Section 2 - Manpower
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Section 3 - Physical Infrastructure (As per specifications) Location building, sanitation Electricity Water supply
Section 4 - Equipment (As per list)
Section 5 - Drugs (As per essential drug list)
Section 6 - Furniture (As per standards)
Section 7 - Quality Control
Section 8 - Views of Beneficiaries about Sub Centre Condition of their Health Certain knowledge of health programs and services which government running for them Availability of specific services
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II.
List of questions for Survey of Primary Health Centre Questions related to Primary Health Center had been divided in nine major sections and then sub section of those main sections.
Section 1- Services Assured Services available Treatment of specific cases MCH Care including Family Planning; Availability of specific services Monitoring and Supervision activities
Section 2- Manpower
Section 3- Training of personnel during previous (full) year
Section 4- Physical Infrastructure (As per specifications) Location Building, Sanitation Electricity Water supply
Section 5 - Equipment (As per list)
Section 6 - Drugs (As per essential drug list)
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Section 7- Furniture ( As per standards)
Section 8 - Quality Control
Section 9 - Views of Beneficiaries about PHC Condition of their Health Certain knowledge of health programs and services which government running for them Availability of specific services
III.
List of questions for Survey of Community Health Centre Questions related to Community Health Center had been divided in nine major sections and then sub sections of those main sections.
Section 1 - Services Specialist services available
Section 2- Manpower Clinical Manpower Support Manpower
Section 3 - Investigative Facilities
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Section 4 - Physical Infrastructure (As per specifications) Location Building, Sanitation Electricity Water supply Section 5 - Equipment (As per list)
Section 6 - Drugs (As per essential drug list)
Section 7- Furniture ( As per standards)
Section 8 - Quality Control
Section 9 - Views of Beneficiaries about CHC Condition of their Health Certain knowledge of health programs and services which government running for them Availability of specific services
B. Data sources While the information available in published sources was obtained and used wherever necessary, the major part of the data required for the study was generated through a sample survey.
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Thus, some district level statistics on health care infrastructure and health indicators were obtained from published documents, but the health care institution (SC/CHC/PHC) specific information and household level data had to be generated through collection of micro level information by the field units of VOP.
C. Methods for analysis Factor analysis technique was employed to examine the structure of the relationship among variables representing the perceived quality dimensions of healthcare services in Uttar Pradesh. The necessary data base was built through collection of both quantitative and qualitative data at various levels. To assess the location and coverage of health centers data pertaining to population coverage vis-a-vis norm prescribed, distance of sample and district Headquarters were collected. The information on availability and adequacy of health care service infrastructure, like, manpower, equipment, physical facilities was collected through health center level. To examine the utilization of referral services, the data on number of routine as well as referred cases attended at health centers per annum were collected. Besides, to assess the effectiveness of health centers, the primary information on accessibility and acceptability of health care services to the people was collected from beneficiaries. Thus, the requisite data base for the study was generated through the instruments of observation structured at different levels and also through discussions with Govt. Health functionaries. The
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instruments of observation were structured at six levels i.e. Sub Centre, CHC, PHC, knowledgeable person, patient and non-patient.
D. Participatory Techniques The study design was finalized in a meeting of the Heads of the Regional Offices of the VOP held on at the Regional Hq. The Head in turn held two Orientation Programs for field staff, one at Lucknow on 1th & 2th 2012 and on 17th & 18th September, 2012 . In these orientation programs, all the instruments prepared for the study were explained to the respective field teams of the selected districts.
E. Study Limitations The study has a number of limitations due to sampling and measurement methods. This study is not a pure experiment, because the intervention facilities were not randomly assigned, and the same patients were not interviewed at baseline and follow-up periods. A potential bias is that patients were interviewed for satisfaction at the facilities which may bias results upward. However, the effect should not be different between project and control sites at baseline and follow-up periods, so that the difference of difference measures should still be valid. The estimates of monthly averages for outpatient visits contained data that were incomplete, particularly at the PHCs. Although the project and control sites for outpatient visits were matched on district, this thin sample might not produce robust estimates.
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We could not find a systematic bias in the data, but we believe that the net effect of these changes is a random increase in the amount of error in our measurements. However, it does not change the main findings that utilization increased for all, especially the wealthier groups and that satisfaction with services increased at the CHCs and PHCs, and more consistently for the wealthier groups than the poor. Finally, caution must be used in interpreting the patient satisfaction ratings. Differences in perceptions may not be due to actual differences in quality. For example, it is not clear if CHC going groups express higher levels of satisfaction because the quality of services for them is better or because they have lower expectations.
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4. Survey findings
a) Findings from CHCs I.
Governmental norms for CHCs for reference CHCs are being established and maintained by the State Government under MNP/BMS program. As per minimum norms, a CHC is required to be manned by four medical specialists i.e. Surgeon, Physician, Gynecologist and Pediatrician supported by 21 paramedical and other staff. It has 30 in-door beds with one OT, X-ray, Labor Room and Laboratory facilities. It serves as a referral Centre for 4 PHCs and also provides facilities for obstetric care and specialist consultations.
II.
Section wise Survey Findings from CHCs Section 1 – Services
Services
Availability 72% NonAvailability 28%
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Section 2- Manpower
Manpower
Availability 57% NonAvailability 43%
Section 3 - Investigative Facilities
Investigative Facilities
NonAvailability 56% Availability 44%
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Section 4 - Physical Infrastructure (As per specifications)
Physical Infrastructure
Availability
84%
NonAvailability
16%
Section 5 - Equipment (As per list)
Equipment
Availability 95%
NonAvailability 5%
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Section 6 - Drugs (As per essential drug list)
Drugs
Availability 95%
NonAvailability 5%
Section 7- Furniture ( As per standards)
Furniture
Availability 68% NonAvailability 32%
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Section 8 - Quality Control
Quality Control
Availability 90%
NonAvailability 10%
Section 9 - Views of Beneficiaries about CHC
Views of Beneficiaries
NonAvailability 56%
Availability 44%
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III.
District
District Wise Findings
(Availability in percentage) S1 Services S2 Manpow er S3 Investigat ive Facilities Physic al Infrast ructur e S4 S5 Equip ment S6 Drugs S7 Furnitu re S8 Quality Control S9 Views of Beneficia ries
Allahabad Ambedkar Nagar Badaun Baharaich Chandauli Faizabad Kaushambi Lucknow Mahoba Mirjapur Sant Ravidas Nagar Sonebhadra Sultanpur Varanasi
66% 35% 54 49 39 40 61 80 46 36 47 52 48 47
45 40 51 66 43 48 43 35 56 55 46 37 46 44
32 34 23 45 25 45 34 45 56 36 46 56 23 34
67 76 65 76 65 67 76 65 76 65 56 67 76 43
84 55 65 23 57 84 55 65 23 57 64 84 55 64
54 56 67 47 26 54 56 67 47 26 48 54 56 63
67 76 65 76 65 44 35 54 87 56 67 44 35 43
84 55 65 23 57 46 66 46 87 54 67 46 66 55
54 56 67 47 26 37 64 53 61 53 54 37 64 56
IV. 1.
Findings In Detail
Average population covered
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Survey data suggest that a CHC covers an average of 175.2 l thousands people.
2. Health Infrastructure - Availability & Adequacy As the CHCs are required to deliver specialised health care services, it was decided to equip these institutions with suitable diagnostic and investigative facilities. As noted earlier, in addition to the usual staff and facilities, four medical specialists and other complementary Para medical staff and facilities, such as, operation theatre, labour room, pathology laboratory, X-ray machine, refrigerator, generator, etc., were prescribed by the Central Government to enable CHCs to deliver specialized health care services to rural people. A comparison of the availability of staff and facilities in the 26 sample CHCs with their prescribed norms shows wide gaps for the majority of the CHCs. In fact, most of them are not equipped to deliver the intended specialised health care services. In particular, the following inadequacies were observed some CHCs have been sanctioned without sanctioning all the posts of specialists;
Only 30 per cent of (the required posts) the specialists were found to be in position. More than 70 per cent of the samples CHCs are
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running either with one specialist (42%) or without any specialist (29%); The extent of shortfall in Para medical staff is found to be 12 per cent for NMWs, 16 per cent for Dressers and 39 per cent for Radiographers. At the aggregate level, pharmacists and laboratory technicians are found to be in excess of requirement; Out of 26 sample CHCs, operation theatres and labour rooms were not available in 5, pathology laboratories in 12, safe drinking water in 9, ECG machines in 23, X-ray machines in 12 and generators in 23 CHCs; What is more striking is the mis-match between the medical specialists and equipment/ facilities/ staff of CHCs. For example, only 6 sample CHCs had Surgeons with the essential complementary facilities comprising X-ray machines with Radiographers, pathology laboratories with lab-technicians and operation theatres, while 8 CHCs had Surgeons, 26 had operation theatres, etc. Similar mis-match is also noticed in the case of other specialists. All this tends to suggest that not only there is an acute shortage of medical specialists, but there is also a mis-match of facilities and specialists in a majority of CHCs, implying sub-optimal utilization and thin spread of available resources.
3. Utilization of Services Among the sample CHCs only two were found to have been used as referral centres to some extent.
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Eleven 11 CHCs have not attended to any referral cases, while the remaining have been used sub-optimally with an average of 206 cases per year. An attempt has been made in the study to identify the factors that explain the variation in the utilization of services across sample CHCs. Given the location and the coverage of area and population, the utilization rate depends on the ability of CHCs to deliver the complete package of services for specialised treatment. Variations in the availability of specialists, Para-medical staff, facilities for medical investigation, physical infrastructure and the complementarity among these Inputs are found to be responsible for differential utilization rates across CHCs. The above findings, however, should not lead one to conclude that the services of CHCs were not used at all. In fact, the entire sample CHCs were found functioning more like PHCs and attended to a large number of routine/direct cases.
4. Beneficiary’s Views An analysis of the views of the beneficiaries of the rural primary health care institutions revealed that about 57 per cent of them
were either dissatisfied or partially satisfied with the quality of services delivered through sample CHCs.
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The reasons for dissatisfaction stem from the inadequacies of the delivery system. Some of the major reasons for dissatisfaction are: non-availability of doctors, indifferent and non-sympathetic attitudes of doctors and Para medical staff and no availability of prescribed medicines. Of about 62 per cent of the total number of selected beneficiaries of sample CHCs, 76.8 per cent of the indoor patients and 54.8 per cent of the outdoor patients had spent money on getting treatment from CHCs. About 80 per cent of the expenditure of both indoor and outdoor patients was on medicines. Twenty eight (28) per cent of the indoor and 6 per cent of the outdoor patients had to spend more than Rs. 500 on each illness episode. It is interesting to note, however, that a large majority of the beneficiaries did not think that such expenses were a major constraint to the utilization of the services intended to be delivered through these CHCs. On the contrary, most of them expressed their preference for the public health institutions vis-àvis other alternatives.
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b) Findings From PHCs
I.
Governmental norms for PHCs for reference
PHC is the first contact point between village community and the Medical Officer. The PHCs were envisaged to provide an integrated curative and preventive health care to the rural population with emphasis on preventive and promote aspects of health care. The PHCs are established and maintained by the State Governments under the Minimum Needs Program (MNP)/ Basic Minimum Services (BMS) Program. As per minimum requirement, a PHC is to be manned by a two Medical Officer supported by 14 paramedical and other staff. Under NRHM, there is a provision for two additional Staff Nurses at PHCs on contract basis. It acts as a referral unit for 6 Sub Centre. It has 4 - 6 beds for patients. The activities of PHC involve curative, preventive, promote and Family Welfare Services.
II.
Section wise Survey Findings from PHCs
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Section 1 – Services
Services
Availability 72% NonAvailability 28%
Section 2- Manpower
Manpower
Availability 57%
NonAvailability 43%
Section 3 - Investigative Facilities
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Investigative Facilities
NonAvailability 56% Availability 44%
Section 4 - Physical Infrastructure (As per specifications)
Physical Infrastructure
Availability
84%
NonAvailability
16%
Section 5 - Equipment (As per list)
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Equipment
Availability 95%
NonAvailability 5%
Section 6 - Drugs (As per essential drug list)
Drugs
Availability 95%
NonAvailability 5%
Section 7- Furniture ( As per standards)
Furniture
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Section 8 - Quality Control
Quality Control
Availabilit y 90% NonAvailabilit y 10%
Section 9 - Views of Beneficiaries about PHC
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Views of Beneficiaries
NonAvailability 56%
Availability 44%
III.
District
District Wise Findings
S1 Services S2 Manpow er S3 Investigat ive Facilities Physic al Infrast ructur e S4 S5 Equip ment S6 Drugs (Availability in percentage) S7 S8 S9 Furnitu Quality Views of Beneficia re Control ries
Allahabad Aajamgarh Ambedkar Nagar Badaun Baharaich Chandauli Faizabad Lucknow
56 44 54 56 53 87 56 65
76 57 43 76 54 67 43 51
57 67 43 76 54 44 43 56
67 76 56 82 71 74 62 84
78 57 65 54 67 56 67 76
76 67 87 65 75 84 84 55
51 58 62 84 54 44 54 56
56 53 67 76 63 57 43 76
56 53 67 54 43 44 54 56
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Mahoba Muradabad Mirjapur Sant Ravidas Nagar Sonebhadra Sultanpur Varanasi
43 78 54 87 76 77 56
58 61 63 67 54 67 66
53 53 54 54 34 65 43
89 74 89 74 89 85 63
76 54 65 65 54 76 56
65 54 76 56 53 53 53
43 43 57 65 89 74 89
65 43 67 87 74 62 74
65 65 67 54 56 67 65
IV. I.
Findings In Detail
Average area covered
Survey data tells that a PHC covers an average of 74.7l thousand people.
II.
Manpower A drawback in the implementation of the family welfare program was the shortage of skilled and dedicated health
workers at the sub-center level followed by non-availability of a lady doctor at the PHC level. In most of the PHCs, male health workers were not available because of non-recruitment of vacancies during the last several years, as either they were retired or promoted. This has been
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happening at a crucial time when male involvement in family welfare is required. As a result, ANMs have taken on the responsibility of the disease control program. It has made them non- responsible and use this as an alibi for the ineffective implementation of the family welfare program. As the workload of ANMs increased, they were unable to give adequate time to the pregnant women and proper counseling, restricting their services only for providing TT injections and IFA tablets. Recently, a number of ANMs were appointed on contract but salaries were not given making them frustrated and disinterested in the work. The number of ANM supervisors was also found to be inadequate. Many of the health care providers suggested that encouragement to staff is important and regular training to upgrade skills are required. It was observed that ANMs were not well trained in IUD insertion and had no proper knowledge of the signs and symptoms of RTI/STIs.
Majority of the Medical Officer In-Charge (MOIC) opined that the Government should provide training to the workers. It was felt that the Chief Medical Officers (CMO) and Medical Officers (MOs) should give time for training the workers and build their capacity.
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III.
Physical Infrastructure (As per specifications) From the selected PHCs, all the 40 selected PHCs have their own building, but three of them needed major repairs, and most of them needed some repairs. Only three out of the PHC buildings were found to be in a good condition. It was also found that staff quarters were available in most of the PHCs, but doctors were not staying there. Water and sanitary facilities have great influence on health. It has been observed that in most of the PHCs the sources of water supply were either through hand pumps or tube wells. Water supply was reported to be adequate in most of the PHCs. Water supply to the existing toilets was not connected through a pipe. Because of this, although toilet facility was available in all the PHCs, several of them were not cleaned every day. It was found that all PHCs have electricity connection, but the supply of electricity was not regular. In most PHCs electricity supply was between seven to eight hours every day.
On the other hand, all PHCs have their own generator to restore power. Also, it was found that the majority of the PHCs have telephone facility.
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Although vehicles were available in majority of the PHCs, it was not in working condition. Similarly, it was also reported that drivers were not available in majority of the PHCs. In most of the PHCs, labour room and operation theatre was available, but exhaust fan was not fitted. All the PHCs had a separate dispensary room. The survey of infrastructure in the selected PHCs showed that barring the regular supply of electricity, all other facilities were more or less available, but the proper use and maintenance of the existing facilities was not ensured. It was also observed that a large number of posts were lying vacant both among the medical and para medical categories, including that of Medical Officer and male MPHWs (Multi Purpose Health Worker), which are key positions.
Recently, temporary ANMs were appointed known as RCH-ANMs, but their numbers were few in each district. There were also a large number of posts found vacant belonging to other employee category, such as drivers, peons, chaukidars, dais and sweepers. This has an impact on cleanliness and maintenance infrastructure at the PHC level.
IV.
Availability of Equipment and Drugs It was reported that the supply of drugs, vaccines, and contraceptives were regular from district to the PHCs, but the
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supply of vaccines was not adequate and regular, particularly BCG and measles. It is also noted that the records on the distribution of drugs, vaccines and contraceptives were not properly maintained. Usually, contraceptives, vaccines and drugs are equally distributed among all the PHCs. There is a need to rationalize the distribution of contraceptive vaccines and drugs to each PHC. However, ANMs did not have delivery kits, stethoscope and BP instruments.
V.
Knowledge and views of beneficiaries Knowing the availability of facilities at the Primary Health Centres is not adequate unless we also take into account the opinion of the clients. Considering this, it was decided to conduct exit interviews of the clients at the PHCs. There were 265 clients interviewed from 40 PHCs of Uttar Pradesh. The most frequently stated health problem for which the clients sought treatment was for fever, cough and cold, diarrhea, etc.
The purpose of visiting the PHC for family planning, ANC and reproductive health was comparatively less. However, more women came for family planning and child care than men, but there was little difference in treatment seeking for reproductive morbidities.
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Treatment seeking behavior and utilization of services at PHCs shows that family planning was not an important concern for clients who visited the PHC for availing services. Also, reproductive health care seeking is almost negligible at the PHC level. This shows that demand for family planning and reproductive health services from the government sources is not high.
c) Findings from Sub Centers I.
Governmental norms for Sub Centers for reference
The Sub-Centre is the most peripheral and first contact point between the primary health care system and the community. Each Sub-Centre is required to be manned by at least one Auxiliary Nurse Midwife (ANM) / Female Health Worker and one Male Health Worker. Under NRHM, there is a provision for one additional second ANM on contract basis. One Lady Health Visitor (LHV) is entrusted with the task of supervision of six Sub-centres. Sub-Centre are assigned tasks relating to interpersonal communication in order to bring about behavioral change and provide services in relation to maternal and child health, family
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welfare, nutrition, immunization, diarrhea control and control of communicable diseases programs. The Sub-centers are provided with basic drugs for minor ailments needed for taking care of essential health needs of men, women and children. The Ministry of Health & Family Welfare is providing 100% Central assistance to all the Sub-centers in the country since April 2002 in the form of salary of ANMs and LHVs, rent at the rate of Rs. 3000/- per annum and contingency at the rate of Rs. 3200/- per annum, in addition to drugs and equipment kits. The salary of the Male Worker is borne by the State Governments. Each sub-Centre will have an Untied Fund for local action @ Rs. 10,000 per annum (as per NRHM 05-12). This Fund will be deposited in a joint Bank Account of the ANM & Sarpanch and operated by the ANM, in consultation with the Village Health Committee.
II.
Section wise Survey Findings from Sub Centers Section 1 – Services
Services
Availability 72%
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A Survey for scaling of Public Health Units of Uttar Pradesh
Section 2- Manpower
Manpower
Availability 57% NonAvailability 43%
Section 3 - Physical Infrastructure (As per specifications)
Physical Infrastructure
Availability
84%
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A Survey for scaling of Public Health Units of Uttar Pradesh
Availability
A Survey for scaling of Public Health Units of Uttar Pradesh
Section 4 - Equipment (As per list)
Equipment
Availability 95%
NonAvailability 5%
Section 5 - Drugs (As per essential drug list)
Drugs
Availability 95%
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NonAvailability 5%
A Survey for scaling of Public Health Units of Uttar Pradesh
Section6- Furniture (As per standards)
Services
Availability 68% NonAvailability 32%
Section 7 - Quality Control
Quality Control
Availability 90%
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A Survey for scaling of Public Health Units of Uttar Pradesh
Section 8 - Views of Beneficiaries about Sub Centers
Views of Beneficiaries
NonAvailability 56%
Availability 44%
III.
District
District Wise Findings
S1 Service s S2 Manpower S3 Physical Infrastruc ture S4 Equip ment S5 Drugs (Availability in percentage) S6 S7 S8 Furnitu Quality Views of re Control Beneficia ries
Allahabad Aajamgarh Ambedkar Nagar Badaun
45 56 65 63
34 62 84 89
65 67 76 76
43 84 55 65
43 54 56 43
33 43 76 65
45 56 73 45
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Baharaich Chandauli Faizabad Kaushambi Mahoba Mirjapur Sant Ravidas Nagar Sonebhadra Sultanpur Varanasi
36 64 56 45 58 54 87 44 76 67
74 89 74 65 67 76 65 76 65 56
54 65 65 43 84 55 65 23 57 64
54 76 56 43 54 56 67 47 26 48
43 57 65 74 44 35 54 87 56 67
43 67 87 56 46 66 46 87 54 67
45 34 75 56 37 64 53 61 53 54
34 54 46 65 43 78 43 36 74 74
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IV.
Findings In Detail
I.
Average area covered Survey data tells that a Sub-Centre covers an average of 5.8 thousand people. II. General Findings When it comes to basic infrastructure facilities in the sub-centers, it is encouraging that most of the sub-centers seem to have some sort of basic physical structure present with 40 out of 112 subcenters having more than one room. However it is a matter of concern that nearly half the sub-centers did not have electricity or sanitation, and 15 out of 112 sub centers had buildings in poor dilapidated conditions. Water was available in 48 out of 112 of the sub centers but toilets were not available in 33 out of 71 of the sub centers.
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Sub Center should provide contraceptives like pills, condoms as well as generic medicines for common ailments like fever. 46 out of 112 sub-centers reported having contraceptive pills while 41 out of 112 sub-centers had condoms available. Medicine for fever was available in 37 out of 112 sub-centers. Ante-natal services for pregnant women are one of most important service that village level sub centers should provide. It is encouraging that iron-tablets that are meant to be regularly provided to pregnant women were available in around 2/3 of the sub centers. However only 27 out of 112 again sub-centers were reported providing ante-natal check-ups. Basic instruments like weighing machine and blood pressure measuring instruments are needed for pre-natal check-ups: more than half sub-centers did not have weighing machines and 49 out of 112 sub centers did not have instrument for measuring blood pressure. Sub-centers should be able to handle normal deliveries at the local level. However some of the basic requirements to handle a delivery were missing. Nearly half the sub centers did not have a bed and 72 out of 112 did not have curtains near the bed for privacy. Other basic things like gloves were absent in half the sub-centers as well as stove required for sterilizing was missing in 57 out of 112 villages.
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5. CONCLUSIONS
Mostly clean, green and well maintained CHCs and committed team; Very spacious CHC buildings; Lack electricity supply in most CHCs; PHCs and SCs need more maintenance; Power supply is erratic; Generators and inverters not available in most places; Bio Medical Waste management needs attention;
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Mobile medical Units not operationalized; Transport constraints for field workers and patients; Shortage of Human resources at all levels; Those in position work hard to deliver health care; Acute shortage of MPW (M); Training process need fast tracking, multi skill training for doctors, IMNCI, IDSP, SBA training, ASHA training; Limited promotional avenues for doctors and para medicals ; Post-delivery stay in the facilities is very short- need monitoring system; Shortage of space leads to compromise with quality; Delivery load is more on few facilities; New Born care services need strengthening; Passive screening for communicable diseases needs to be strengthened; Active screening for communicable diseases ( Malaria) needs more attention;
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Basic non communicable disease screening fixed day services needed; Hospital level Diabetes , Hypertension clinic, cancer cervix screening, RTI/STI clinics, Integrated counseling and Testing Centres needed in all 24 x 7 facilities; Poor voluntary blood donation – insisting on relative donor; Institutional deliveries improved; Awareness on MCH services very high in the community; Adequate drug supply; Poor availability of MTP/ MVA services; centres needed for provision of tubectomy services; Convergence needs more attention; Lab services at peripheral centers poorly equipped – Lack of reagents and Consumables; ANMs and ASHAs are well accepted and respected in the community; PRIs not uniformly involved for VHSC; VHSC recently instituted but not yet active;
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Clear Guidelines for the use of funds needed; Timely payment to JSY beneficiaries needed; It is commonly known that women are often the last to access health care in a poor family. Distance of the health-center and cost of treatment may act as important factors that determine women’s access to primary healthcare; Given the easy location of the sub centers, it has the potential to increase access to primary healthcare for women; However as the data suggests, many sub-centers lack basic facilities like water, electricity or toilets, which raise serious questions about quality of care provided; UP being one of the worst states when it comes to maternal health indicators, the importance of ante natal care is immense. Much of the problems associated with maternal death can be averted if there is early detection of anemia, low weight, blood pressure etc; However, as the data suggests, more than half the sub centers are not providing antenatal check-ups, thereby increasing the load on higher level of facilities. Sub- centers were found to be ill equipped to handle normal deliveries, with nearly half the subcenters not even having beds. Easy availability of quality contraceptives is integral for women to have control over reproductive decision making and avoid unwanted pregnancies;
Yet, not all sub-centres had even contraceptive facilities;
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6. Recommendations
1. General Recommendations
1. Manpower deficit should be addressed urgently. Mapping of human resource and redistribution is required. More doctors, staff nurse, Public Health Nurse, Pharmacists need to be recruited. General duty medical officers with public health expertise and management skills are to be posted at primary care facilities. For this creation of a public health cadre is very justified. As the clinicians and specialists currently posted at various facilities are neither able to provide specialist services due to lack of facilities not able to implement national health programs and provide leadership to public health team due to lack of managerial skills. 2. The doctors posted at most of the facilities are either specialists or MBBS with clinical orientation. They lack understanding of public health perspectives and integrated approach to health care.
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ANMs recruited in 1980s are old now and not able to deliver with efficiency of young women. A large number of them are going to retire in next couple of years. It is the right time to tackle this issue before a new human resource crisis emerges in this segment. ANMs having become an experienced work force, require to be promoted to supervisory levels and new young ANMs need to be recruited in order to improve field work. 3. It is recommended that public health specialists and specialists in community medicine/family medicine should be posted at the primary health care facilities. They will be able to take care of primary health care needs of the community, implement national health programs and provide managerial/administrative leadership to his team of primary health care. Creation of a separate public health cadre will be able to fulfill this need of public health managers at various levels of health care facility. 4. Training program for MPW(M) and diploma courses for nurses in Maternal and New born care as well as career progression scheme for them may improve their functioning. 5. The working conditions and incentives for working in rural area should be so rewarding that it does not make the incumbent feel disadvantaged compared to his/her counterpart working in urban areas and private sector. 6. Provision of interest free loans for buying moped/two wheelers or providing mopeds may improve out reach service delivery component of primary health care. 7. Community participation and community ownership is grossly lacking. People are not aware of their rights and responsibilities. Sensitization and awareness generation among the people need to
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be improved, particularly in rural areas. The signage showing citizens charters and informing people about salient features of programs like Janani Suraksha Yojana should not be restricted to health facilities. These need to be displayed in villages and prominent market places as well. 8. Monitoring and supervision is another area that needs to be improved. With aging and retirement of LHVs, supervision process is diluted. Through promotion of ANMs and recruitment of new LHVs, this can be taken care of. 9. Shortage of Male Multi Purpose Worker also need to be addressed. 10. Political interference in manpower recruitment as well as in day to governance is a great hindrance in smooth functioning of health care system. Even the involvement of Panchayati Raj Institutions has proved counterproductive in some areas, particularly when it becomes a key determinant in recruitment and transfer of workers, protection of erring workers. Mass media campaigns should also be used to inform the community about the facilities created under these new programs and their benefits. 11. Safety and security of ANMs and other female workers is a matter of concern in some areas. There are plenty of instances of manhandling and molestation of single female workers in the field area and the culprits getting away with. 12. Rationalization of services at different levels following IPH standards is recommended.
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13. Neonatal referral units to be provided in all district hospitals and basic new born care units in all CHCs and 24x7 facilities should be made available. 16. Establish modern blood bank with blood component separation units. 17. Rapid implementation of IDSP should be ensured. 18. Some of the facility buildings are located far from the villages, in a remote isolated corner, thus making it less accessible and a deterrent for ANM to stay there. 19. With the financial incentives being paid to the beneficiaries for services availed, an opportunity presents itself: availability of validated output indicators. A major deficiency of public sector programming, namely availability of only process indicators, can now be overcome. The ability to determine performance of individual providers and centres can become a very useful management tool for strengthening the programs in the time ahead. 20. With JSY gaining rapid acceptance, the number of obstetric emergencies being brought to the institutions will also go up. The system needs to get itself ready for these cases at CHC and PHC levels. 21. Non communicable diseases control program and vector borne diseases control programs are not yet being implemented at the peripheral level. This needs to be strengthened. 22. Nutrition supplementation, nutrition rehabilitation and provision of food for mothers after delivery and after tubectomy
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operations should be made at all facilities where these services are being provided. 24. Better monitoring and supportive supervision of all programs should be ensured by monthly review by district magistrates, use of structured inspection forms and follow up schedules. 25. Rapid grievance redress for staff and beneficiaries should be ensured. 26. Community participation and social audit should be encouraged.
Appendix -I
List of Surveyed Centers
CHCs:
Sl. No. District CHC Saray Lili Jasra Shankergarh Kaundhiara Akbarpur Tanda Ujhani
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1
Allahabad
2 3
Ambedkar Nagar Badaun
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4 5 6 7 8 9 10 11 12
Baharaich Chandauli Faizabad Kaushambi Lucknow Mahoba Mirjapur Sant Ravidas Nagar Sonebhadra Sultanpur Varanasi
Kakrala Dataganj Motipur Naugarh Chakia Sohawal Bara Chinhat Bakshi Ka Talab Charkhari Rajgarh Suriyawn Chopan Myopur Ghorawal Akhand Nagar Puarikala Cholapur Gangapur
13 14
PHCs:
Sl. No. 1 District Allahabad PHC Kotwa Bara Jaari Badagaon Jamnipur Bewana Tarakhurd
2
Ambedkar Nagar
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3
Azamgarh
Badhalganj Jagat Kadarchowk Myoun Usaihat Uswan Sujauli Amba Shikarganj
4
Badaun
5
Baharaich
6
Chandauli
7 8 9
Faizabad Kaushambi Lucknow
Chakia Amdaha Milkipur Sohawal Karari Baishkhari Kathwara Rustampur Varni Allipur Narauli Akrauli Patehra Kala Padri Kasya Mahjuda Myopur Salkhan Parsona Mudila Rupaipur
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10
Muradabad
11 12
Mirjapur Sant Ravidas Nagar
13
Sonebhadra
14
Sultanpur
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Harhua 15 Varanasi Badagaon Chiraigaon Pindara
Sub Centers:
Sl. No.
District
Sub Center Gara Katra Biharia Jorhat Baghla Biharia Kalyanpur Gulalpur Bara Khanti Jaari Janwa GaraaaKatra Bansgaon Airakala
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1
Allahabad
2
Aajamgarh
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3
Ambedkar Nagar
Tisaura Ilfatganj Banwa Tajpur Naipura Naugawan Asharfa Bad Kataria Silwan Makdumpur Kathauna Sanjarpur Abdullaganj Viola Naushera Sisora Sathara Bhundi Gathauna Kurau Sarali Bahu Nagla Bhagautipur Hazaratpur Uharpur Kishni Gidhaul Ikari Jagat Chilor Monipatti Gautra
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4
Badaun
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Koda Jaikaran Nagariya Chikan Bilhari Myaun Dehat Harendi Labhari Gurgaon JamalPur Ranviganj Varsua 5 Baharaich Gathuna Girijapuri Amdaha 6 Chandauli Nevadganj Shikarganj Baliakala Shahganj Raunai Para Hasanpur Baiskati Karari Pawara Mangura Pindara Gubara Sirchanpur Danpur Saibasa Chak Sayyadpur Mawana Alam Aadilpur
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7
Faizabad
8
Kaushambi
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9
Mahoba
Ranipur Gaurahi Kharela Kanhaipur Sarson Golhanpur Bachaura Aitraila Raikara Dashrath Nevada Kusuda Chattar Shahpur Persona Bhawana Kadia Shivdwar Salkhan Pehadwa Markundi Kirbil Nipraj Aarang Pani Lilasi Loknathpur Unurukha Bahauddin Mailkpur Unrukha Rupaipur Shivrampur Velvariya
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10
Mirjapur
11
Sant Ravidas Nagar
12
Sonebhadra
13
Sultanpur
14
Varanasi
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Aanei Aapar Mangari Machli gaon Parmandapur Belva Saray Mohan Nathaipur
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